Co–Occurring Alcohol Use Disorder and Schizophrenia (PDF) by Alena Amund


									                         Co-Occurring Alcohol Use

                         Disorder and Schizophrenia

                                        Robert E. Drake, M.D., Ph.D., and Kim T. Mueser, Ph.D.

               Alcohol use disorder (AUD) is the most common co-occurring disorder in people with
               schizophrenia. Both biological factors and psychosocial factors are thought to contribute to
               this co-occurrence. Schizophrenia patients with AUD are more likely to have social, legal, and
               medical problems, compared with other people with schizophrenia. AUD also complicates the
               course and treatment of schizophrenia. KEY WORDS: comorbidity; AODD (alcohol and other
               drug dependence); schizophrenia; prevalence; disease susceptibility; disease course; self-
               medication; reinforcement; dopamine; neurotransmission; social adjustment; treatment
               complications; combined modality therapy; correlation analysis; literature review

      chizophrenia is a severe and dis­                            abuse other substances as well. Current         related disorder marked by the same
      abling psychiatric disorder charac­                          understanding of contributing factors,          symptoms as schizophrenia but lasting
      terized by persistent delusions,                             correlated problems, effect on course of        less than 6 months) also met the criteria
hallucinations, disorganized speech,                               illness, and treatment implications is          for an AUD diagnosis at some time
disorganized behavior, and negative                                similar for different substances of abuse.      during their lives and that 47 percent
symptoms such as the absence of emo­                                                                               met the criteria for any substance use
tional expression or a lack of motivation                                                                          disorder (excluding nicotine dependence)
or initiative (American Psychiatric                                Prevalence and                                  (Regier et al. 1990). Rates of substance
Association [APA] 1994). Alcohol use                               Contributing Factors                            use disorder tend to be higher among
disorder1 (AUD) commonly co-occurs                                                                                 males and among people of both genders
with schizophrenia. This article reviews                           Schizophrenia is frequently complicated         and all ages in institutional settings,
several aspects of AUD among people                                by comorbid disorders such as medical           such as hospitals, emergency rooms,
with schizophrenia, including the preva­                           illnesses, mental retardation, and sub-
lence of this co-occurrence, biological and                        stance abuse. Substance use disorder is         2
                                                                                                                    The ECA study was a nationwide survey that used DSM–IV
psychosocial factors that contribute to                            the most frequent and clinically signifi­       criteria to determine the prevalence of psychiatric disorders
this relationship, correlated problems                             cant comorbidity in this population,            in the general population and among people in treatment.

dually diagnosed people experience, the                            and alcohol is the most common sub-
effects of AUD on the course and out-                              stance of abuse, other than nicotine            ROBERT E. DRAKE, M.D., PH.D., and
come of schizophrenia, treatment issues,                           (nicotine is much more prevalent than           KIM T. MUESER, PH.D., are professors in
and public policy implications. People                             any other substance of abuse in this            the departments of psychiatry and commu­
with schizophrenia and AUD frequently                              population) (Cuffel 1996). Undoubtedly,         nity and family medicine at Dartmouth
                                                                   the availability of alcohol and the fact        Medical School and the New Hampshire-
                                                                   that it is legal contribute to its widespread   Dartmouth Psychiatric Research Center,
 The term “alcohol use disorder” in this article refers to the     abuse among people with schizophrenia           Lebanon, New Hampshire.
disorder defined by criteria for alcohol abuse or dependence
in the American Psychiatric Association’s Diagnostic and
                                                                   as well as in the general population.
Statistical Manual of Mental Disorders, Fourth Edition             The Epidemiologic Catchment Area                The writing of this paper was supported
(DSM–IV) (APA 1994). The terms “alcohol use disorder”              (ECA) study2 found that 33.7 percent            by U.S. Public Health Services grants
and “alcohol abuse” are used interchangeably in this article.The
definitions for these terms vary among studies reviewed
                                                                   of people with a diagnosis of schizophre­       MH–59383 and MH–52872 from the
and are frequently based on earlier versions of the DSM.           nia or schizophreniform disorder (a             National Institute of Mental Health.

Vol. 26, No. 2, 2002                                                                                                                                                        99
jails, and homeless shelters. This holds         Roberts 1999). The neurobiology of            are available. The first type, cross-sectional
true for people with and without                 schizophrenia is similarly unclear            studies, collects data at one point in
schizophrenia (Regier et al. 1990).              (Chambers et al. 2001).                       time. The second type, longitudinal
    The high rates of AUD and other                  The third hypothesis suggests that        studies, collects data at several points
substance use disorders in people with           people with schizophrenia are especially      over a period of time. Cross-sectional
schizophrenia appear to be determined            vulnerable to the negative psychosocial       studies indicate that AUD among people
by a complex set of factors (described           effects of substance use because the          with schizophrenia is associated with
below) (Mueser et al. 1998). People              schizophrenia syndrome produces im­           numerous manifestations of bad out-
with schizophrenia probably use alcohol          paired thinking and social judgment           comes and poor quality of life (refer-
and other drugs for many of the same             and poor impulse control. Thus, even          red to generally as poor adjustment),
reasons as others in society, but several        when using relatively small amounts of        including increased recurrence of psychi­
biological, psychological, and socioen­          psychoactive substances, these people         atric symptoms, psychosocial instability,
vironmental factors have been hypothe­           are prone to develop significant substance-   other substance use disorders, violence,
sized to contribute to this population’s         related behavioral problems that qualify      victimization, legal problems, medical
high rates of substance use disorders.           them for a diagnosis of substance use         problems such as HIV infection and
                                                 disorder (Mueser et al. 1998).                hepatitis, family problems, and institu­
                                                                                               tionalization in hospitals and jails
Biological Factors                                                                             (Drake and Brunette 1998). People with
                                                 Psychological and
There are three possible biological factors.                                                   schizophrenia and AUD are particularly
First, many clinicians and researchers
                                                 Socioenvironmental Factors                    prone to unstable housing situations
have asserted that people with schizophre­       Psychological and socioenvironmental          and homelessness. Although these people
nia use alcohol and other drugs to self-         factors also appear to contribute to the      often reject medications and outpatient
medicate in an attempt to alleviate the          co-occurrence of schizophrenia and AUD.       treatment, they nevertheless represent a
symptoms of schizophrenia or the side            People with schizophrenia and AUD             high cost to the treatment system because
effects of the antipsychotic medications         often report that they use alcohol and        they receive a high rate of hospital-based
prescribed for schizophrenia (Chambers           other drugs to alleviate the general dys­     services—relapse, as well as familial,
et al. 2001). Research evidence does             phoria of mental illness, poverty, lim­       psychosocial, legal, housing, and other
not strongly support this view, however.         ited opportunities, and boredom; they         crises force them into emergency care
For example, alcohol abuse often pre-            also report that substance use facilitates    (Dickey and Azeni 1996).
cedes schizophrenia; specific drugs of           the development of an identity and a              The common explanation for these
abuse are not selected in relation to            social network (Dixon et al. 1990).           correlated problems is that alcohol use
specific symptoms; and various substances        An entire generation of adults with           causes or exacerbates poor adjustment
of abuse produce a range of different            schizophrenia in the United States has        among people with schizophrenia. Many
effects but generally exacerbate rather          grown up during the era of deinstitu­         other factors could, however, explain
than relieve symptoms of schizophrenia           tionalization (Lamb and Bachrach              the relationships between AUD and poor
(Chambers et al. 2001).                          2001). Although residing predominantly        adjustment found in cross-sectional stud­
    Second, the underlying neuropatho­           in the community rather than in hospi­        ies. For example, schizophrenia patients
logical abnormalities of schizophrenia           tals, these people still have had limited     who abuse alcohol often abuse other
(i.e., the abnormalities in the brain that       vocational, recreational, and social          substances, fail to take medications, and
characterize schizophrenia) are thought          opportunities (caused by factors such         live in stressful circumstances without
to facilitate the positive reinforcing effects   as illness, stigma, and segregation).         a strong support network, as described
of substance use (Chambers et al. 2001).         Further, they have experienced down-          above. They may also have other inherent
A common neurological basis for                  ward social drift into poor urban living      differences from schizophrenia patients
schizophrenia and for the reinforcing            settings, where they are regularly exposed    without AUD, thereby confounding
effects of substance use may predispose          to substance abuse and substance-             the comparison between schizophrenia
people to both conditions. This common           abusing social networks (Lamb and             patients with AUD and those without
basis involves the dysregulation of the          Bachrach 2001).                               AUD.
brain chemical (i.e., neurotransmitter)                                                            Researchers are also accumulating
dopamine. This would explain why                                                               longitudinal data regarding the course
people with schizophrenia prefer drugs           Correlated Problems                           and outcome of co-occurring schizophre­
such as nicotine and a class of antipsy­         and the Effects of AUD                        nia and AUD. Short-term studies last­
chotic medications that increase dopa-           on the Course and                             ing 1 year or less of patients in traditional
mine transmission in some areas of the           Outcome of Schizophrenia                      mental health treatment systems indicate
brain. Of course, the reinforcing effects                                                      that they are prone to negative outcomes,
of alcohol use involve multiple neuro­           Two general types of studies of the           such as continuing alcohol abuse or
transmitter systems, and the mechanisms          problems experienced by people with           dependence, high rates of homeless­
at work are not yet clear (Koob and              co-occurring schizophrenia and AUD            ness, disruptive behavior, psychiatric

100                                                                                                           Alcohol Research & Health
                                                                                             Alcohol Use and Schizophrenia

hospitalization, victimization, and incar­    abuse services (Bellack and DiClemente             Although the need to provide inte­
ceration. For example, one typical study      1999; Onken et al. 1997; Ries 1994).           grated, multidisciplinary services is clear,
of outpatients with schizophrenia found       There is also accumulating research            the numerous specific treatments that
that those with co-occurring AUD had          support for the effectiveness of the           are in use or in development need to be
higher rates of hospitalization and depres­   integrated treatment approaches that           tested regarding their individual effective­
sion compared with those with schizophre­     have evolved over the past two decades         ness and their effectiveness in combina­
nia only (Cuffel and Chase 1994).             (Drake et al. 1998).                           tion (Drake et al. 2001). For example,
    Several studies, including some stud­        Integrated approaches to treatment          specific individual, group, family, and
ies that tracked participants’ progress       for patients with schizophrenia and            self-help approaches to integrated treat­
over time (rather than collecting data        AUD are generally offered through the          ment are described in the literature, but
on patients’ histories at some later point)                                                  few studies validate or compare these
indicate that dually diagnosed people                                                        different approaches. Similar comments
who become abstinent (compared with                                                          pertain to potential psychopharmaco­
those who do not) show more positive                                                         logic treatments and to approaches to
results in other related areas, such as
lower psychiatric symptoms and decreased
                                                  In practice, patients                      psychiatric rehabilitation. Several retro­
                                                                                             spective studies indicate that the antipsy­
rates of hospitalization (Drake et al.            with co-occurring                          chotic medication clozapine may be
1996). For example, people in the ECA                                                        particularly helpful to patients with
study with schizophrenia and AUD                      mental and                             schizophrenia and AUD, but the
who attained abstinence had decreased
rates of depression and hospitalization
                                                     substance use                           mechanisms of action for the effects on
                                                                                             both illnesses are unclear, and controlled
at 1-year followup (Cuffel 1996). In a           disorders have rarely                       research is needed to establish the effi­
long-term followup study of schizophre­
nia patients by Drake and colleagues                received needed                          cacy and effectiveness of this treatment
                                                                                             (Green et al. 1999).
(1998), those who attained stable absti­
nence showed dramatic improvements
                                                       treatments.                               Several approaches to housing, social
                                                                                             skills training, vocational services, money
in many domains, including decreased                                                         management, and supervision have also
symptoms, decreased institutionalization,                                                    been recommended but not rigorously
increased psychosocial stability, and                                                        tested. Another important area of inves­
self-reported improvements in quality         use of multidisciplinary treatment teams       tigation is treatment for those patients
of life. These positive findings have         that provide outreach, comprehensive           who do not respond to standard outpa­
fueled attempts to develop more effec­        services, and stage-wise treatments            tient approaches. Clinicians need to
tive interventions for AUD among              (described below). Outreach is needed          know which patients should be offered
schizophrenia patients. As described          because these patients are often demor­        residential treatments, contingency
below, such interventions include those       alized and reluctant to engage in treat­       management (i.e., providing positive
that integrate treatment for schizophre­      ment. Comprehensive services are vital         consequences for desired behaviors and
nia and for AUD.                              because recovery involves building skills      withholding those consequences or
                                              and supports to pursue a meaningful            providing negative consequences for
                                              life rather than just managing symptoms        undesired behaviors), adjunctive medi­
Treatment                                     or illnesses. Stage-wise treatment assumes     cations, money management, or other
                                              that patients recover from two serious         second-line interventions (i.e., interven­
Historically, the mental health and sub-      disorders over time, in stages, and with       tions for patients who do not respond to
stance abuse treatment systems in the         help from treatment providers. Patients        standard treatment) (Drake et al. 2001).
United States have been separate, and         with schizophrenia and AUD generally
traditional approaches to treating people     pass through four stages of treatment:
with co-occurring disorders have involved         1. Engagement, which involves build­       Public Policy
parallel or sequential treatment in these     ing a trusting treatment relationship
separate systems. In practice, patients           2. Persuasion, which entails develop­      Although the testing and refinement of
with co-occurring mental and substance        ing motivation to manage both illnesses        specific interventions, the development
use disorders have rarely received needed     and pursue recovery                            of treatment matching, and strategies
treatments (Watkins et al. 2001) and              3. Active treatment, which encom­          to overcome nonresponsiveness are
have generally experienced poor outcomes      passes development of the skills and           important issues, progress toward inte­
(Drake et al. 1996; Ridgely et al. 1987).     supports needed for illness management         grating mental health and substance abuse
As a result, there has been widespread        and recovery                                   services has been minimal. Barriers
endorsement by patients, clinicians,              4. Relapse prevention, which involves      exist at all levels (e.g., organizational,
administrators, and researchers for inte­     strategies to avoid and minimize the effects   financial, and educational) and public
grating mental health and substance           of relapses (Osher and Kofoed 1989).           policy at the Federal, State, regional,

Vol. 26, No. 2, 2002                                                                                                                 101
and local levels has thus far failed to pro-   chosocial and pharmacological inter­                    DRAKE, R.E.; ESSOCK, S.M.; SHANER, A.; ET AL.
mote widespread adoption of either             ventions also need further development                  Implementing dual diagnosis services for clients
                                                                                                       with severe mental illness. Psychiatric Services 52:
integrated treatments for dual disorders       and testing, particularly for patients                  469–476, 2001.
or other evidence-based practices in the       who do not respond to basic integrated
mental health and substance abuse treat­       interventions. s                                        GOLDMAN, H.H.; GANJU, V.; DRAKE, R.E.; ET AL.
                                                                                                       Policy implications for implementing evidence-based
ment systems (Goldman et al. 2001).                                                                    practices. Psychiatric Services 52:1591–1597, 2001.
Clinicians, patients, and family mem­
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